Using the Gardner Cascade, a system developed by a Denver Health infectious disease physician that estimates how many individuals with HIV in the United States engage in various steps of care – from diagnosis through viral suppression – Denver Health developed a multistep program that helps ensure HIV-infected people remain on the care continuum.
1. Appropriately targeted HIV testing programs, quick results
The organization expanded HIV testing to community-based sites frequented by the gay community, such as the city’s three gay bathhouses. They also expanded testing within the emergency department and maximized the use of rapid testing to ensure positive results are immediately communicated to patients. Denver Health uses verbal opt-out testing to obtain 99 percent HIV screening in pregnant women. Those found to be infected receive optimal antiretroviral therapy, which has led to no cases of perinatal HIV transmission over the past decade.
2. Immediate response, link to care
To ensure immediate care for those infected, Denver Health implemented an HIV Linkage to Care Program. Case managers engage with patients on the day of HIV diagnosis, provide free CD4 and HIV viral load testing for all people with positive tests to more rapidly assess short-term risks for HIV complications, and immediately link them to care providers throughout the metropolitan Denver area. In addition, a transitional case management program facilitates smooth transitions into Denver County jail and the Colorado Department of Corrections and back out into the community upon release.
3. Effective prevention
Recognizing that people with HIV continue to have healthy sex lives, Denver Health trained providers to improve the quantity and quality of prevention-related discussions. These discussions correlate with screening for STDs to reduce the effect of those infections on HIV transmission.
4. Retention in HIV care
Using a computer-based tool, Denver Health identifies patients with missed clinic visits, gaps in care, or suboptimal adherence to antiretroviral therapy. Patient navigators use this information to reach out to patients to discover barriers to care and work toward solutions, which may range from scheduling a mental health or financial screening to referring patients to a social worker or substance abuse treatment center. The organization also engages community organizations, such as the Ryan White–funded Colorado AIDS Project and Servicios de La Raza, that provide case management services to build a more comprehensive system of care.
5. Continuous evaluation
Continuously refined informatics allow Denver Health to assess outcomes, provide feedback to appropriate programs, and rigorously evaluate the impact of these interventions on individuals and the community as a whole.
“The integration of clinical services and public health within the same organization allowed us to overcome the division between care and prevention, develop a comprehensive approach to the local HIV epidemic, and then track the effects across our community.” Mark Thrun, MD, director of HIV/STD prevention and control at Denver Health
Since implementing its program, Denver Health has seen a number of positive results:
- A test positivity rate continuously above the 1 percent threshold recommended by the Centers for Disease Control and Prevention.
- An increase in the proportion of people linked into HIV care after diagnosis from 70 percent in 2005 to 89 percent in 2011.
- An increase in long-term retention in care rates from 62 percent in 2010 to 74 percent in 2012.
- An increase in the proportion of newly diagnosed individuals with undetectable HIV levels within 18 months of their HIV diagnosis from 27 percent in 2005 to 45 percent in 2009.
- A decrease in the number of patients who present with HIV at Denver Health from 43 cases per 100,000 people in 2005 to 21 cases per 100,000 in 2012.
For more information on Denver Health’s HIV programs, please contact:
Mark Thrun, MD
Director of HIV/STD Prevention and Control